not-yet-known not-yet-known not-yet-known unknown Sheath Rupture in Figure-of-Eight Suturing: A Case Report and Risk Reduction Strategies

not-yet-known not-yet-known not-yet-known unknown Sheath Rupture in Figure-of-Eight Suturing: A Case Report and Risk Reduction Strategies | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 18 June 2025 V1 Latest version Share on not-yet-known not-yet-known not-yet-known unknown Sheath Rupture in Figure-of-Eight Suturing: A Case Report and Risk Reduction Strategies Authors : Takahiro Kobayashi 0009-0007-5239-8224 [email protected] , Yasushi Oginosawa 0000-0002-0955-7791 , Yuki Nakamura , Taro Miyamoto 0000-0003-4743-9902 , Yasunobu Yamagishi 0000-0001-8257-7468 , Katsuhide Hayashi , Kazunobu Kawakami , and Masaharu Kataoka Authors Info & Affiliations https://doi.org/10.22541/au.175028955.50273805/v1 216 views 126 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract This case report describes a rare complication of sheath rupture during Figure-of-Eight suturing following catheter ablation. A 44-year-old male undergoing electrophysiological testing experienced sudden sheath rupture upon removal, necessitating emergency surgical retrieval. The mechanism likely involved three factors: accidental needle puncture causing initial damage, excessive suture tension creating structural compromise, and shearing forces during removal precipitating complete rupture. Preventive strategies include maintaining appropriate needle placement away from the sheath, controlling suture tension, and retaining an intraluminal device during suturing for mechanical protection. This case emphasizes the importance of standardized procedural protocols and thorough operator training to enhance patient safety during vascular closure procedures. Sheath Rupture in Figure-of-Eight Suturing: A Case Report and Risk Reduction Strategies Short title: Sheath Rupture in Figure-of-Eight Suturing Takahiro Kobayashi, MD a , Yasushi Oginosawa, MD, PhD, a Yuki Nakamura,MD a , Taro Miyamoto, MD, PhD a , Yasunobu Yamaghishi, MD, PhD a , Katsuhide Hayashi, MD, PhD a , Kazunobu Kawakami, MD, PhD b , Masaharu Kataoka, MD, PhD a a Department of Cardiology, University of Occupational and Environmental Health, Japan b Department of Cardiology, Kumamoto Rosai Hospital, Yatsushiro, Kumamoto, Japan Corresponding Author Takahiro Kobayashi Department of Cardiology, University of Occupational and Environmental Health, Japan 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan Email: [email protected] Data Availability Statement: All data underlying the results are available as part of the article, and no additional source data are required. Funding: Funding for this study was not provided. Conflicts of Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. not-yet-known not-yet-known not-yet-known unknown Ethics Approval Statement: This study did not require ethics approval as it is a single case report and did not involve research procedures beyond standard clinical care. Patient Consent Statement: Written informed consent was obtained from the patient for the preparation and publication of this case report. Permission to Reproduce Material From Other Sources: Acknowldgements: We would like to thank Editage (www.editage.jp) for English language editing. This case report describes a rare complication of sheath rupture during Figure-of-Eight suturing following catheter ablation. A 44-year-old male undergoing electrophysiological testing experienced sudden sheath rupture upon removal, necessitating emergency surgical retrieval. The mechanism likely involved three factors: accidental needle puncture causing initial damage, excessive suture tension creating structural compromise, and shearing forces during removal precipitating complete rupture. Preventive strategies include maintaining appropriate needle placement away from the sheath, controlling suture tension, and retaining an intraluminal device during suturing for mechanical protection. This case emphasizes the importance of standardized procedural protocols and thorough operator training to enhance patient safety during vascular closure procedures. Keywords : figure-of-eight suture, sheath injury, catheter ablation, hemostasis, preventive countermeasures Introduction Electrophysiological studies and catheter ablation are the cornerstones of arrhythmia treatment. Technological advances have improved the effectiveness of the procedure; however, the management of vascular access sites remains critical. According to a large study, vascular complications occur in 1.53% of catheter ablation procedures. 1 Conventional hemostatic procedures require prolonged manual compression, which can be uncomfortable for patients and require prolonged immobilization. To address these limitations, figure-of-eight (FoE) suturing and vascular closure devices have been introduced as alternatives to expedite hemostasis and promote early ambulation. 2−4 The FoE suture technique is particularly attractive because of its simplicity and cost-effectiveness. Despite its advantages, FoE suturing is associated with risks such as sheath rupture, especially due to improper needle placement, excessive suture tension, or material failure (Figure 1). To the best of our knowledge, this is the first report of direct complications associated with FoE suturing. In this case report, we focus on the complications of sheath rupture, explore its underlying mechanisms, and propose risk-reducing measures. Case Report Patient Background and Procedure A 44-year-old male patient presented with an incidental Brugada type I electrocardiographic pattern. The patient had no family history of ventricular fibrillation or syncope. However, he underwent electrophysiological testing to determine the necessity for an implantable cardioverter-defibrillator. 5 The patient had no significant medical history, and the pre-procedure evaluation yielded no notable findings. The procedure was performed under local anesthesia with ultrasound-guided femoral vein access, and two 5 Fr, 25 cm sheaths were inserted into the femoral veins. Electrophysiological studies were completed without any complications. Complication and Management The following materials were used for hemostasis after the procedure: a 1/2 circle, 33 mm diameter suture needle and 1-0 silk FoE suture thread. Initially, there were no complications during suturing; however, mild resistance was observed during sheath removal, followed by an abrupt rupture of the sheath wall and subsequent partial detachment (Figure 2). The use of a thicker sheath and snare was considered a retrieval method for the fractured sheath. However, given the length of the fractured sheath and its proximity to the femoral puncture site, a more distal venous approach was considered necessary. Consequently, emergency surgical intervention was performed, involving an incision of the groin, exposure of the femoral vein under direct vision, and removal of the sheath fragment using a snare. The procedure was successfully completed, and hemostasis was achieved without further complications. The patient was discharged on postoperative day 3. Discussion This case highlights the risk of sheath rupture as a significant complication of FoE suturing. The analysis suggested that inadvertent needle penetration created a perforation that expanded under suture tension, leading to a full rupture. The experimental data confirm that minor sheath defects propagate under mechanical stress (Figure 3). Prevention Methods • Needle insertion position is a critical risk factor for perforation. The risk of perforation increases when the needle is placed too close to the puncture site. Therefore, it is imperative to maintain a safe distance from the sheath to mitigate the risk of injury. This distance should be equivalent to half the suture needle length for sheath insertion at 45°, or half the radius for insertion at 60°. • The material characteristics of the sheath are also significant. In our experiments, the polyether block amide sheaths used during ablation exhibited superior elasticity and resilience compared with polymer sheaths, thereby preventing the needle from penetrating the sheath wall. • The retention of catheters or dilators during suturing served as a mechanical buffer preventing the needle from penetrating the sheath wall. not-yet-known not-yet-known not-yet-known unknown Prevention Strategies Control the needle insertion position and avoid suturing proximal to the insertion site. Hold the intraluminal devices during suturing. Implement standardized procedural protocols and operator training. Conclusion FoE suturing is an effective method for vascular closure, but presents risks, including sheath rupture. This case emphasizes the importance of correct needle placement, controlled suture tension, and appropriate selection of sheath material. Retaining the intraluminal device during suturing provides an additional protective measure. Standardized protocols and enhanced operator training are essential to mitigate complications. Further research is necessary to optimize hemostasis strategies for catheter ablation. References 1. Deshmukh A, Patel NJ, Pant S, et al. In-hospital complications associated with catheter ablation of atrial fibrillation in the United States between 2000 and 2010: analysis of 93,801 procedures. Circulation 2013;128:2104-2112. 2. Lakshmanadoss U, Wong WS, Kutinsky I, Khalid MR, Williamson B, Haines DE. Figure-of-eight suture for venous hemostasis in fully anticoagulated patients after atrial fibrillation catheter ablation. Indian Pacing Electrophysiol J 2017;17:134-139. 3. Okada M, Inoue K, Tanaka K, et al. Efficacy and safety of figure-of-eight suture for hemostasis after radiofrequency catheter ablation for atrial fibrillation. Circ J 2018;82:956-964. 4. Al-Ahmad A, Mittal S, DeLurgio D, et al. Results from the prospective, multicenter AMBULATE-CAP trial: Reduced use of urinary catheters and protamine with hemostasis via the Mid-Bore Venous Vascular Closure System (VASCADE® MVP) following multi-access cardiac ablation procedures. J Cardiovasc Electrophysiol 2021;32:191-199. 5. Priori SG, Wilde AA, Horie M, et al.; Heart Rhythm Society; European Heart Rhythm Association; Asia Pacific Heart Rhythm Society. Executive summary: HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes. Europace 2013;15:1389-1406. Figures Information & Authors Information Version history V1 Version 1 18 June 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords clinical: catheter ablation – non-rf energy sources clinical: catheter ablation – wpw/avrt Authors Affiliations Takahiro Kobayashi 0009-0007-5239-8224 [email protected] Sangyo Ika Daigaku Toshokan View all articles by this author Yasushi Oginosawa 0000-0002-0955-7791 Sangyo Ika Daigaku Toshokan View all articles by this author Yuki Nakamura Sangyo Ika Daigaku Toshokan View all articles by this author Taro Miyamoto 0000-0003-4743-9902 Sangyo Ika Daigaku Toshokan View all articles by this author Yasunobu Yamagishi 0000-0001-8257-7468 Sangyo Ika Daigaku Toshokan View all articles by this author Katsuhide Hayashi Sangyo Ika Daigaku Toshokan View all articles by this author Kazunobu Kawakami Kumamoto Rosai Byoin View all articles by this author Masaharu Kataoka Sangyo Ika Daigaku Toshokan View all articles by this author Metrics & Citations Metrics Article Usage 216 views 126 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Takahiro Kobayashi, Yasushi Oginosawa, Yuki Nakamura, et al. not-yet-known not-yet-known not-yet-known unknown Sheath Rupture in Figure-of-Eight Suturing: A Case Report and Risk Reduction Strategies. 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